Checklist on safe surgery practice not found in any medical records of 15 patients at Tipperary Hospital

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A checklist to ensure HSE policy on safe surgery is followed was not found in any healthcare records of a random sample of 15 patients who had procedures at Tipperary University Hospital in Clonmel, Co Tipperary last year, according to an internal audit.
A report by HSE auditors on emergency, elective and day procedures at Tipperary University Hospital (TippUH) concluded that it could only provide limited assurance about the adequacy and effectiveness of the governance, risk management and internal control system in the hospital in relation to safe surgery.
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HSE auditors had carried out a retrospective random sample on the healthcare records of 15 patients out of a total of 96 who underwent surgery or an endoscopy at TippUH over a seven-day period in July 2024.
The audit was designed to check that planned surgery was clearly documented and consent was obtained and recorded for each procedure.
Although TippUH had amalgamated aspects of the checklist based on the HSE's National Policy and Procedure for Safe Surgery into its care plans, the report found the actual checklist was not present in any medical records reviewed in relation to a random sample of 15 procedures carried out at the hospital.
It said there was a risk that variances between the hospital's care plans and the official checklist 'may result in sub-optimal implementation' of the HSE's policy on safe surgery 'with potential adverse consequences for patients.'
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Among questions on the checklist which were not included in the hospital's care plan were ones asking if the procedure had been confirmed with a parent or guardian in the case of children and if prophylactic antibiotics were required.
Others related to checking a healthcare record number matched the number on the patient's wristband and if protocols were in place if the patient suffered unexpected blood loss.
The audit found that TippUH included some questions that were completed after an anaesthetic or block was administered which should have been carried out beforehand under the HSE checklist.
It also revealed that the hospital did not document in medical records if a site-specific marking on a patient had been checked in the case of two patients.
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HSE auditors found that TippUH was unable to provide records about the number of medical staff who had completed a mandatory course on safe surgery.
They also concluded that recommended pre-surgery briefings among medical staff at TIppUH resembled 'nursing huddles' as opposed to multidisciplinary briefings.
Noting that not all members of the theatre team were present at such meetings, the report said non-attendance of key members could result in critical information not being transferred which could result in potential harm to patients.
HSE auditors issued a total of four recommendations including that all components of the HSE's checklist for safe surgery be incorporated into the relevant care plans at TippUH or alternatively that the checklist be adopted as a standalone document by the hospital.
The report noted that TippUH management had agreed to the implementation of all the recommendations.